A nurse is caring for a client who gave birth 2 hr ago.
The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.
Evaluate the firmness of the uterus (fundus).
Obtain a type and crossmatch.
Administer oxytocin infusion.
Initiate oxygen therapy by nonrebreather mask.
The Correct Answer is A
The correct answer is choice A.
Choice A rationale:
Evaluating the firmness of the uterus (fundus) is the first action the nurse should take when a client’s blood pressure drops postpartum. A soft or “boggy” uterus can indicate uterine atony, a leading cause of postpartum hemorrhage, which can lead to hypotension.
Choice B rationale:
Obtaining a type and crossmatch is important if the client needs a blood transfusion, but it is not the first action the nurse should take.
Choice C rationale:
Administering oxytocin infusion can help contract the uterus and control bleeding, but the nurse should first assess the uterus.
Choice D rationale:
Initiating oxygen therapy can help if the client is hypoxic, but the nurse should first assess the uterus.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B.
Choice A rationale:
Placing a baby on their stomach while sleeping is not recommended due to the risk of Sudden Infant Death Syndrome (SIDS).
Choice B rationale:
Removing extra blankets from the crib is a safety measure to prevent suffocation and overheating, which can lead to SIDS.
Choice C rationale:
Padding the mattress in the crib can pose a suffocation risk for the baby.
Choice D rationale:
It’s recommended for newborns to sleep in the same room as their parents for at least the first six months to reduce the risk of SIDS.
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
While oxytocin sensitivity is important for labor, there is no evidence to suggest that Braxton Hicks contractions increase oxytocin sensitivity.
Choice B rationale:
Prostaglandins play a crucial role in labor by causing the cervix to soften and dilate and the uterus to contract. However, there is no evidence to suggest that Braxton Hicks contractions increase the release of prostaglandins.
Choice C rationale:
While maternal comfort is important during labor, there is no evidence to suggest that Braxton Hicks contractions make maternal breathing easier.
Choice D rationale:
Braxton Hicks contractions help in softening and ripening the cervix, which is an important part of preparing for labor.
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